MD Anderson Cancer Center
Japanese Medical Exchange Program
2019

Ayaka Kashimura, Bachelor of Pharmaceutical Sciences
Department of Pharmacy
University of Tsukuba Hospital

Personal Mission and Vision from JME Program 2019

●Mission（Japanese）
薬剤師としてがん患者に対しゲノム情報に基づく適切な薬物治療の支援をする（English）
To support appropriate drug treatment based on genomic information for cancerpatients as a pharmacist.

●Vision（Japanese）
ゲノム情報を活用した抗がん剤治療によりがん患者の生活の質向上を目指す（English）
To realize the high quality of life for cancer patients through anticancer drug treatmentusing genomic information.

1. Purpose
Personal Purposes of Japanese Medical Exchange 2019 (JME2019):Through the program in MD Anderson Cancer Center (MDACC),
1. Understand about the multidisciplinary cancer team and the role ofpharmacists in cancer team in MDACC.
2. Find out why MDACC is the number 1 cancer hospital in the United States.
3. Clarify my mission and vision and develop my career plan as a pharmacist.
2. Methods
At the beginning
JME 2019 member are selected by ''The 2nd Team Science Oncology Workshop'' byMDACC and Japan Team Oncology Program at Showa University Hatanodai Campus
from January 25 to 27 2019.
Participants
2 Physician, 2 pharmacists, 2 nurses
The training was conducted in MDACC from August 23 to September 27, 2019 on thefollowing topics:
3. Program
The multidisciplinary team approach in cancer care in MDACC
MDACC has a job called Mid-level provider that does not exist in Japan. Theoccupations that correspond to mid-level providers are Nurse Practitioner (NP),Physician Assistant (PA), and Clinical Pharmacist (CP). These occupations support thework of doctors. Care providers strive to focus on patient education to provide patientcentered care.
A. Outpatient clinic
One example is outpatient treatment of breast tumor internal medicine that we visited
this time. At first, doctors, nurses and pharmacists will share patient information on theday and discuss options for treatment interventions. When a patient arrives at theexamination room, a registered nurse (RN), who is a regular nurse in Japan, firstmeasures the vital signs of the patient and collects basic information such as
symptoms of the disease and current internal medicine. Based on this information, theNP or PA will conduct an examination, extract the current problem, and provide

feedback to the doctor. The doctor then takes an enough time to explain the medicalcondition and treatment policy to the patient and decides a treatment method according
to the patient's intention. CP provides patient education such as explanation of drugs
and management methods for side effects as needed, such as when patients start
chemotherapy or when regimens change.
B. Outpatient treatment center
I was very surprised that the number of beds in MDACC was about 700. However,after visiting the outpatient treatment center and outpatient clinics, I realized thattreatment that I thought was impossible in an outpatient setting would be possible withsystematic support. I will give an example in hematology. Patients who engraft after
hematopoietic stem cell transplantation visit the Ambulatory Treatment Center (ATC)daily for 2 weeks after discharge. The doctor meets once a week, but the NP andpharmacist meet other days. After that, they go once every 2 days for 3 weeks and 3times a week until 6 weeks. He must be in Houston for three months, but then he will
be handed over to a local cancer doctor. I felt that a short hospital stay could be
realized because the visit interval after discharge was fixed every period and there wascareful follow-up.
C. Patients in MDACC
Many patients we met at MDACC were aware that they were members of team
medicine. They were enthusiastic about studying the disease and how to treat it, andoften asked medical questions. They also tried to understand clinical trials. We felt
strongly that they were coming to MDACC to treat cancer. As for current medication,
they can say the name of it when they are asked by medical staffs. I was surprised thatthey can answer the reason why the doctor instructed them to stop when they did nottake the drug listed in the letter of introduction. After explaining chemotherapy to apatient in Japan, I always ask the patient “Do you have any questions?” Their reply isends with a single phrase, “I don't know about the treatment, so I'll leave everything toyou.” Considering that medical treatment is the job of a medical staffs, patients havestopped thinking about treatment on their own. How can the patient live their own way
to the end? What should we do to get the patient aware of participating in thetreatment? During this training, I felt the hint was in patient education.
D. Patient education
The hospital has three libraries called learning centers. Patients and their families cancollect information from books and brochures on disease, treatment, and prevention foreach type of cancer. Information about clinical trials will also be provided if requested.
In addition, free patient classes were held and there were various programs to receive
education according to interest.
At an outpatient clinic in the breast oncology department, it can take 40 minutes ormore to inform the patient about the cancer. The doctor looked at the patient, snuggled
up to the patient and the patient's family, and held the patient's hand silently. He built
trust through verbal and non-verbal communication so that patients could accept it.
MDACC medical personnel are learning the following communication skills:
・ Breaking Bad News -SPIKES・ Addressing Emotions -CLASS and EVE・ Discussing Medical Errors -CONES・ Cultural Competence -BALANCE・ Challenging Emotional Conversations
with Patients and Families -BUSTER・ Effective Communication in Supervision -TIMEREven if they understand it, it is difficult to put it into practice, but they used these skills
naturally and promoted their daily medical care smoothly. I felt that the education ofmedical professionals was also an important factor in patient education.
E. Role of pharmacist
The pharmacy department is classified into three categories. The first is a technician
who does not have a pharmacist license in charge of dispensing and asepticadjustment. The second is Operational Pharmacist who has a pharmacist license
checks prescription and adjustment of injections. The third is a CP belongs to theclinical department team and provides drug proposals to other specialists andeducation for patients. By subdividing and sharing the work of pharmacists in this way,the environment where CP can concentrate on clinical work was established. I felt thatthey were able to work efficiently. CP needs to complete a two-year resident program
called PGY1 and PGY2. In the resident system, they learn knowledge in specialized
fields such as oncology, nutrition, infectious diseases, emergency medicine, andpalliative medicine, and at the same time develop problem-solving skills based onevidence, discussion skills, and presentation skills. They were responsible forpharmacological management and patient education by providing proper use ofmedication, check of interaction, pharmacokinetics, management of side effect,
guidance at hospital discharge. CP has a contract with a specific physician and canorder a chemotherapy regimen by co-signing. RN and PA also have the right to orderchemotherapy, but because it is necessary to adjust the dose according to laboratory
values such as liver function and kidney function, it was almost always left for CP whois familiar with drug treatment.
F. Professor Ueno’s lecture
Once a week, we received an opportunity to discuss with Professor Ueno about
mission and vision, Core Value, and Leadership. We filled in an Individual Development
Plan (IDP) sheet: how you have worked on the items in Education, Research, Patient
Care, Administration, Self-Development, and Service. If we did not go as planned lastyear, we wrote what was the problems. We have described the goals for this fiscal year
and what resources are necessary to achieve the goals. While it is necessary thatgoals in each field be consistent with mission and vision, it seemed very difficult to set
each individual goal to go in the same direction.
Also, if you know the Core Value of a team member, you will know what the person istaking care of and it will be easier to communicate. I also learned that by avoiding
options that violate my Core Value as much as possible, I could spend comfortably.
G. Janis’s lecture
Janis gave lectures on communication, Leadership, dealing with Difficult
Conversation, Self-Awareness, Teamwork, Career and Life. I learned that it is difficult totake a leadership in a team when we don’t know about ourselves well. Leadership is
not only for people in limited positions or positions, but it is necessary for teamwork thateveryone recognizes and carries out the style of a leadership suitable for that person.
H. Mentorship
I got the opportunity to be instructed by two Mentors, Neelam and Melvin, CP. I
regularly interacted with Mentor and brushed up mission and vision. I was very
convinced by Neelam's words, “It's important to be interested in the specialty of one
disease, but a pharmacist is a drug specialist and needs a generalist's perspective”.
Even if you are familiar with cancer treatments, patients often have other diseases aswell as cancer. The doctors also heard that there are cases where prescriptions are
difficult for non-specialized drugs, so I wanted to have a wide range of drug knowledge
so that pharmacists who know medicines can make proposals.

4. Results
A. Team ProjectAs a summary of this training, we were divided into teams A and B for presentations.
We present mission and vision of Team A.
●Mission
To improve patient ’s satisfaction in oncology outpatient clinic through multidisciplinary
collaboration●VisionTo optimize medical care for cancer patients to improve their self-care management
skills and make them actively participate in their treatment by offering information andeducation from multidisciplinary team
Recently in Japan, the waiting time for medical treatment is long, but the conversationand consultation time with doctors are very short. More than half of patients talk todoctors in less than 10 minutes. In addition, patient satisfaction in outpatient treatment
is lower than in-hospital care. (Ministry of Health, Labor and Welfare 2017 survey) On
the other hand, the satisfaction level of patients who received outpatient chemotherapy
at MDACC is as high as 80%. In MDACC, outpatient treatment through multiprofessional collaboration was very fulfilling, taking a completely different style fromJapan. This time, Team A focused on improving Japanese outpatient clinics, the themeof which could be considered through MDACC outpatient clinics.
The problem with outpatient clinics in Japan is that doctors have many roles to playand have little time to talk to patients, making it difficult to communicate properly. Also,
there is little time to examine physical findings. Nurses spend time on non-specialty
tasks, such as guiding patients to the laboratory and reserving patients, and have
limited time to interact with patients and their families. Most hospitals do not havepharmacists in outpatient clinics, so it is difficult to suggest prescriptions in advance,
and there is no opportunity to talk with doctors, so it may not be possible to explain
according to the doctor's intention when delivering the drug.
The solution to these problems were to hire medical assistants to reduce the burdenof medical affairs, and to leave the areas that other professionals are good at. We
thought it was very important to create an environment where good communication
between healthcare professionals was possible. Specifically, an interdisciplinary room
was set up for outpatient clinics, and nurses, pharmacists and medical staff wereplaced there to examine how to team up with doctors. In this case, because thetreatment proceeds based on the consensus of the treatment policy by the team, it
seems that there is little difference in the medical staff when explaining to the patient.
Through this team project, I was able to learn it is important to listen to the otherpeople’s opinions, ask appropriate questions, understand the ideas underlying theopinions, and that team members respect the team's interests rather than individualinterests. The fact that each of the three team members was able to demonstrateleadership and create a single mission and vision was a great confidence in shaping
future team medical care.
B. The Reason why MDACC is the No. 1 cancer hospital in the United States
In MDACC, work is subdivided according to occupations, and a system is in place toincrease expertise and concentrate on work. In addition, they have introduced
mechanization in the field that machines are good at, enabling efficient operations. The
background that the environment has been prepared is that has always continued todiscuss the problems, consider and implement improvement measures, and makecorrections if it did not work. MD Anderson President Peter WT Pisters, MD, MHCM
says, “The No. 1 ranking carries with it the responsibility to be a leader in the cancer
field, and we are continually striving for improvement. " I felt that the current MDACC
was created by observing problems from various viewpoints and conducting thoroughfactor analysis.
C. Leadership as a Pharmacist
It is important that pharmacists have a wide range of drug treatment knowledge as
generalists and accumulate knowledge in specialized fields. Pharmacists provide
pharmacokinetics, drug interactions, side effect monitoring, and management
knowledge and information to other medical professionals such as doctors and nurses
to use drugs appropriately. I thought that the ability of pharmacists could be utilized byimproving patient adherence and improving self-management skills through patienteducation.
D. Career Development
Before this training, my mission and vision were abstract. I learned that to achieve
something, it's hard to do it if you can't imagine it clearly. Narrow down the mostinfluential areas by setting the maximum impact targets you want to achieve in yourcareer and applying them to the impact range and strength parameters. Helped toclarify the abstract mission and vision more clearly and create more detailed andfamiliar goals. Generally setting goals and dreams, we consider whether we have theability, whether we have the money, whether it is feasible or impossible. With the advice
that they were unnecessary at first, I came up with a lot of ideas and finally decided in
one direction.
5. Prospects
I thought that the medical system in MDACC was reasonable. One of the reasons forthis is that business has become more electronic and mechanized, and work wasefficient. Because of the presence of technicians, pharmacists work only forpharmacists’ job, so enough time was secured for communication with healthcare
professionals and patients. In addition, in Japan, how pharmacists in hospitals areengaged in drug treatment other than dispensing operations is gradually spreading inJapan, but in MDACC they were recognized by other medical professionals andpatients as well. It was clear what the pharmacist wanted as a medicine specialist andwhat the pharmacist could offer and give back. In Japan, I felt that it was necessary to
introduce a technician and mechanization so that a pharmacist could make the most of
his skills as a professional.
In MDACC, continuous improvement activities were conducted through factoranalysis. A system that continuously improves the quality is necessary when
considering the survival of the organization as it changes every day. When settinggoals, we started by collecting data, analyzed them, compared them with the current
situation and problems at the current stage, and set the goals after specifying what wasnecessary in the future. In daily life, it is difficult to create an opportunity to set goals byfollowing such a process because of daily work but create a system that cancontinuously perform improvement activities according to changes in the times andenvironment I think that is important.
I personally feel that it was a very good experience to be able to participate in thistraining, which is still in the developing stage of the 4th year of the pharmacist. I would
like to keep in touch with mentors and JME friends I met at JME and make efforts
toward mission and vision.
6． Acknowledgements
I would like to thank everyone from the bottom of my heart for their help and support
for JME program 2019. Especially, I would like to express my sincere thanks to Dr.
Ueno who guided us from before to the end of the program and Dr. Joyce Neumann,Ms. Janis Yadiny and all other US mentors who guided us at MDACC. My mentor Ms.
Neelam K Patel and Mr. Melvin Rivera were always thinking about me and gave me a
lot of valuable advice. Mr. Fueki, Ms. Marcy Sanchez, and JME 2018 members
supported us from before the beginning of the program. I also thank manyorganizations and individuals for their kindness and support for the program. I would
also like to express my gratitude great JME 2019 members.